=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639410913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDI L KINNEY DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2013
-----------------------------------------------------
Last Update Date | 03/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3115 OCEAN FRONT WALK
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-8729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-488-3597
-----------------------------------------------------
Fax | 858-746-4041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3639 MIDWAY DR STE B296
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-488-3597
-----------------------------------------------------
Fax | 858-746-4041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 39984
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------